White Rock Medical Center

All Charges

Charge

Type

Setting

Price

CHWR BASIC GRAVITY ADM SET

Facility

$118.74

Hospital Charge Code	5420020
Hospital Revenue Code	270
Min. Negotiated Rate	$10.69
Max. Negotiated Rate	$85.49
Rate for Payer: Amerigroup CHIP/Medicaid	$10.69
Rate for Payer: BCBS of TX Blue Advantage	$35.62
Rate for Payer: BCBS of TX Blue Essentials	$42.75
Rate for Payer: BCBS of TX PPO	$47.50
Rate for Payer: Cash Price	$80.74
Rate for Payer: Cigna Medicaid	$85.49
Rate for Payer: Molina CHIP/Medicaid	$85.49
Rate for Payer: Multiplan Auto	$77.18
Rate for Payer: Multiplan Commercial	$77.18
Rate for Payer: Multiplan Workers Comp	$77.18
Rate for Payer: Parkland Medicaid	$85.49
Rate for Payer: Scott and White EPO/PPO	$59.37
Rate for Payer: Superior Health Plan CHIP/Medicaid	$85.49
Rate for Payer: Superior Health Plan EPO	$16.15

CHWR BASIC GRAVITY ADM SET

Facility

$118.74

Hospital Charge Code	5420020
Hospital Revenue Code	270
Rate for Payer: Cash Price	$80.74

CHWR BD NEXIVA IV CATH 22g

Facility

$57.27

Hospital Charge Code	5420150
Hospital Revenue Code	270
Rate for Payer: Cash Price	$38.94

CHWR BD NEXIVA IV CATH 22g

Facility

$57.27

Hospital Charge Code	5420150
Hospital Revenue Code	270
Min. Negotiated Rate	$5.15
Max. Negotiated Rate	$41.23
Rate for Payer: Amerigroup CHIP/Medicaid	$5.15
Rate for Payer: BCBS of TX Blue Advantage	$17.18
Rate for Payer: BCBS of TX Blue Essentials	$20.62
Rate for Payer: BCBS of TX PPO	$22.91
Rate for Payer: Cash Price	$38.94
Rate for Payer: Cigna Medicaid	$41.23
Rate for Payer: Molina CHIP/Medicaid	$41.23
Rate for Payer: Multiplan Auto	$37.23
Rate for Payer: Multiplan Commercial	$37.23
Rate for Payer: Multiplan Workers Comp	$37.23
Rate for Payer: Parkland Medicaid	$41.23
Rate for Payer: Scott and White EPO/PPO	$28.64
Rate for Payer: Superior Health Plan CHIP/Medicaid	$41.23
Rate for Payer: Superior Health Plan EPO	$7.79

CHWR BIOPSY CORE CONTAINER

Facility

$107.83

Hospital Charge Code	8031834
Hospital Revenue Code	272
Rate for Payer: Cash Price	$73.32

CHWR BIOPSY CORE CONTAINER

Facility

$107.83

Hospital Charge Code	8031834
Hospital Revenue Code	272
Min. Negotiated Rate	$9.70
Max. Negotiated Rate	$77.64
Rate for Payer: Amerigroup CHIP/Medicaid	$9.70
Rate for Payer: BCBS of TX Blue Advantage	$32.35
Rate for Payer: BCBS of TX Blue Essentials	$38.82
Rate for Payer: BCBS of TX PPO	$43.13
Rate for Payer: Cash Price	$73.32
Rate for Payer: Cigna Medicaid	$77.64
Rate for Payer: Molina CHIP/Medicaid	$77.64
Rate for Payer: Multiplan Auto	$70.09
Rate for Payer: Multiplan Commercial	$70.09
Rate for Payer: Multiplan Workers Comp	$70.09
Rate for Payer: Parkland Medicaid	$77.64
Rate for Payer: Scott and White EPO/PPO	$53.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$77.64
Rate for Payer: Superior Health Plan EPO	$14.66

CHWR BREAST LOC NEEDLE ALL

Facility

$67.90

Hospital Charge Code	8032780
Hospital Revenue Code	272
Rate for Payer: Cash Price	$46.17

CHWR BREAST LOC NEEDLE ALL

Facility

$67.90

Hospital Charge Code	8032780
Hospital Revenue Code	272
Min. Negotiated Rate	$6.11
Max. Negotiated Rate	$48.89
Rate for Payer: Amerigroup CHIP/Medicaid	$6.11
Rate for Payer: BCBS of TX Blue Advantage	$20.37
Rate for Payer: BCBS of TX Blue Essentials	$24.44
Rate for Payer: BCBS of TX PPO	$27.16
Rate for Payer: Cash Price	$46.17
Rate for Payer: Cigna Medicaid	$48.89
Rate for Payer: Molina CHIP/Medicaid	$48.89
Rate for Payer: Multiplan Auto	$44.13
Rate for Payer: Multiplan Commercial	$44.13
Rate for Payer: Multiplan Workers Comp	$44.13
Rate for Payer: Parkland Medicaid	$48.89
Rate for Payer: Scott and White EPO/PPO	$33.95
Rate for Payer: Superior Health Plan CHIP/Medicaid	$48.89
Rate for Payer: Superior Health Plan EPO	$9.23

CHWR BX CORE GUN ALL

Facility

$1,211.05

Hospital Charge Code	8174828
Hospital Revenue Code	272
Min. Negotiated Rate	$108.99
Max. Negotiated Rate	$871.96
Rate for Payer: Amerigroup CHIP/Medicaid	$108.99
Rate for Payer: BCBS of TX Blue Advantage	$363.31
Rate for Payer: BCBS of TX Blue Essentials	$435.98
Rate for Payer: BCBS of TX PPO	$484.42
Rate for Payer: Cash Price	$823.51
Rate for Payer: Cigna Medicaid	$871.96
Rate for Payer: Molina CHIP/Medicaid	$871.96
Rate for Payer: Multiplan Auto	$787.18
Rate for Payer: Multiplan Commercial	$787.18
Rate for Payer: Multiplan Workers Comp	$787.18
Rate for Payer: Parkland Medicaid	$871.96
Rate for Payer: Scott and White EPO/PPO	$605.52
Rate for Payer: Superior Health Plan CHIP/Medicaid	$871.96
Rate for Payer: Superior Health Plan EPO	$164.70

CHWR BX CORE GUN ALL

Facility

$1,211.05

Hospital Charge Code	8174828
Hospital Revenue Code	272
Rate for Payer: Cash Price	$823.51

CHWR BX NEEDLE KIT MAX CORE 14G X 10CM

Facility

$176.60

Hospital Charge Code	8082741
Hospital Revenue Code	272
Rate for Payer: Cash Price	$120.09

CHWR BX NEEDLE KIT MAX CORE 14G X 10CM

Facility

$176.60

Hospital Charge Code	8082741
Hospital Revenue Code	272
Min. Negotiated Rate	$15.89
Max. Negotiated Rate	$127.15
Rate for Payer: Amerigroup CHIP/Medicaid	$15.89
Rate for Payer: BCBS of TX Blue Advantage	$52.98
Rate for Payer: BCBS of TX Blue Essentials	$63.58
Rate for Payer: BCBS of TX PPO	$70.64
Rate for Payer: Cash Price	$120.09
Rate for Payer: Cigna Medicaid	$127.15
Rate for Payer: Molina CHIP/Medicaid	$127.15
Rate for Payer: Multiplan Auto	$114.79
Rate for Payer: Multiplan Commercial	$114.79
Rate for Payer: Multiplan Workers Comp	$114.79
Rate for Payer: Parkland Medicaid	$127.15
Rate for Payer: Scott and White EPO/PPO	$88.30
Rate for Payer: Superior Health Plan CHIP/Medicaid	$127.15
Rate for Payer: Superior Health Plan EPO	$24.02

CHWR BX TISSUE CORE 17Gx 10CM

Facility

$422.05

Hospital Charge Code	8182909
Hospital Revenue Code	272
Rate for Payer: Cash Price	$286.99

CHWR BX TISSUE CORE 17Gx 10CM

Facility

$422.05

Hospital Charge Code	8182909
Hospital Revenue Code	272
Min. Negotiated Rate	$37.98
Max. Negotiated Rate	$303.88
Rate for Payer: Amerigroup CHIP/Medicaid	$37.98
Rate for Payer: BCBS of TX Blue Advantage	$126.61
Rate for Payer: BCBS of TX Blue Essentials	$151.94
Rate for Payer: BCBS of TX PPO	$168.82
Rate for Payer: Cash Price	$286.99
Rate for Payer: Cigna Medicaid	$303.88
Rate for Payer: Molina CHIP/Medicaid	$303.88
Rate for Payer: Multiplan Auto	$274.33
Rate for Payer: Multiplan Commercial	$274.33
Rate for Payer: Multiplan Workers Comp	$274.33
Rate for Payer: Parkland Medicaid	$303.88
Rate for Payer: Scott and White EPO/PPO	$211.03
Rate for Payer: Superior Health Plan CHIP/Medicaid	$303.88
Rate for Payer: Superior Health Plan EPO	$57.40

CHWR CATH DRAINAGE SAFE TTRAY 6FR16CM

Facility

$279.00

Service Code	HCPCS C1729
Hospital Charge Code	8081990
Hospital Revenue Code	278
Min. Negotiated Rate	$69.75
Max. Negotiated Rate	$139.50
Rate for Payer: Cash Price	$189.72
Rate for Payer: Cigna Commercial	$69.75
Rate for Payer: Multiplan Auto	$139.50
Rate for Payer: Multiplan Commercial	$139.50
Rate for Payer: Multiplan Workers Comp	$139.50
Rate for Payer: Scott and White EPO/PPO	$139.50

CHWR CATH DRAINAGE SAFE TTRAY 6FR16CM

Facility

$279.00

Service Code	HCPCS C1729
Hospital Charge Code	8081990
Hospital Revenue Code	278
Min. Negotiated Rate	$25.11
Max. Negotiated Rate	$200.88
Rate for Payer: Amerigroup CHIP/Medicaid	$25.11
Rate for Payer: BCBS of TX Blue Advantage	$83.70
Rate for Payer: BCBS of TX Blue Essentials	$100.44
Rate for Payer: BCBS of TX PPO	$111.60
Rate for Payer: Cash Price	$189.72
Rate for Payer: Cigna Medicaid	$200.88
Rate for Payer: Molina CHIP/Medicaid	$200.88
Rate for Payer: Multiplan Auto	$139.50
Rate for Payer: Multiplan Commercial	$139.50
Rate for Payer: Multiplan Workers Comp	$139.50
Rate for Payer: Parkland Medicaid	$200.88
Rate for Payer: Scott and White EPO/PPO	$139.50
Rate for Payer: Superior Health Plan CHIP/Medicaid	$200.88
Rate for Payer: Superior Health Plan EPO	$37.94

CHWR COBAN WRAP

Facility

$45.82

Hospital Charge Code	8024031
Hospital Revenue Code	270
Rate for Payer: Cash Price	$31.16

CHWR COBAN WRAP

Facility

$45.82

Hospital Charge Code	8024031
Hospital Revenue Code	270
Min. Negotiated Rate	$4.12
Max. Negotiated Rate	$32.99
Rate for Payer: Amerigroup CHIP/Medicaid	$4.12
Rate for Payer: BCBS of TX Blue Advantage	$13.75
Rate for Payer: BCBS of TX Blue Essentials	$16.50
Rate for Payer: BCBS of TX PPO	$18.33
Rate for Payer: Cash Price	$31.16
Rate for Payer: Cigna Medicaid	$32.99
Rate for Payer: Molina CHIP/Medicaid	$32.99
Rate for Payer: Multiplan Auto	$29.78
Rate for Payer: Multiplan Commercial	$29.78
Rate for Payer: Multiplan Workers Comp	$29.78
Rate for Payer: Parkland Medicaid	$32.99
Rate for Payer: Scott and White EPO/PPO	$22.91
Rate for Payer: Superior Health Plan CHIP/Medicaid	$32.99
Rate for Payer: Superior Health Plan EPO	$6.23

CHWR CONNECTING TUBE

Facility

$66.89

Hospital Charge Code	8177545
Hospital Revenue Code	270
Min. Negotiated Rate	$6.02
Max. Negotiated Rate	$48.16
Rate for Payer: Amerigroup CHIP/Medicaid	$6.02
Rate for Payer: BCBS of TX Blue Advantage	$20.07
Rate for Payer: BCBS of TX Blue Essentials	$24.08
Rate for Payer: BCBS of TX PPO	$26.76
Rate for Payer: Cash Price	$45.49
Rate for Payer: Cigna Medicaid	$48.16
Rate for Payer: Molina CHIP/Medicaid	$48.16
Rate for Payer: Multiplan Auto	$43.48
Rate for Payer: Multiplan Commercial	$43.48
Rate for Payer: Multiplan Workers Comp	$43.48
Rate for Payer: Parkland Medicaid	$48.16
Rate for Payer: Scott and White EPO/PPO	$33.45
Rate for Payer: Superior Health Plan CHIP/Medicaid	$48.16
Rate for Payer: Superior Health Plan EPO	$9.10

CHWR CONNECTING TUBE

Facility

$66.89

Hospital Charge Code	8177545
Hospital Revenue Code	270
Rate for Payer: Cash Price	$45.49

CHWR CONNECTION TUBING

Facility

$87.80

Hospital Charge Code	8185585
Hospital Revenue Code	272
Min. Negotiated Rate	$7.90
Max. Negotiated Rate	$63.22
Rate for Payer: Amerigroup CHIP/Medicaid	$7.90
Rate for Payer: BCBS of TX Blue Advantage	$26.34
Rate for Payer: BCBS of TX Blue Essentials	$31.61
Rate for Payer: BCBS of TX PPO	$35.12
Rate for Payer: Cash Price	$59.70
Rate for Payer: Cigna Medicaid	$63.22
Rate for Payer: Molina CHIP/Medicaid	$63.22
Rate for Payer: Multiplan Auto	$57.07
Rate for Payer: Multiplan Commercial	$57.07
Rate for Payer: Multiplan Workers Comp	$57.07
Rate for Payer: Parkland Medicaid	$63.22
Rate for Payer: Scott and White EPO/PPO	$43.90
Rate for Payer: Superior Health Plan CHIP/Medicaid	$63.22
Rate for Payer: Superior Health Plan EPO	$11.94

CHWR CONNECTION TUBING

Facility

$87.80

Hospital Charge Code	8185585
Hospital Revenue Code	272
Rate for Payer: Cash Price	$59.70

CHWR CT GUIDE NEEDLE PLACEMENT

Facility

$4,508.00

Service Code	HCPCS 77012
Hospital Charge Code	5056361
Hospital Revenue Code	350
Min. Negotiated Rate	$129.03
Max. Negotiated Rate	$3,245.76
Rate for Payer: Amerigroup CHIP/Medicaid	$405.72
Rate for Payer: BCBS of TX Blue Advantage	$129.03
Rate for Payer: BCBS of TX Blue Essentials	$154.84
Rate for Payer: BCBS of TX PPO	$172.82
Rate for Payer: Cash Price	$3,065.44
Rate for Payer: Cash Price	$3,065.44
Rate for Payer: Cigna Medicaid	$3,245.76
Rate for Payer: Molina CHIP/Medicaid	$3,245.76
Rate for Payer: Multiplan Auto	$2,930.20
Rate for Payer: Multiplan Commercial	$2,930.20
Rate for Payer: Multiplan Workers Comp	$2,930.20
Rate for Payer: Parkland Medicaid	$3,245.76
Rate for Payer: Scott and White EPO/PPO	$171.59
Rate for Payer: Superior Health Plan CHIP/Medicaid	$3,245.76
Rate for Payer: Superior Health Plan EPO	$613.09

CHWR CT GUIDE NEEDLE PLACEMENT

Facility

$4,508.00

Service Code	HCPCS 77012
Hospital Charge Code	5056361
Hospital Revenue Code	350
Rate for Payer: Cash Price	$3,065.44

CHWR DILATOR ANY SIZE

Facility

$77.63

Hospital Charge Code	8174035
Hospital Revenue Code	272
Min. Negotiated Rate	$6.99
Max. Negotiated Rate	$55.89
Rate for Payer: Amerigroup CHIP/Medicaid	$6.99
Rate for Payer: BCBS of TX Blue Advantage	$23.29
Rate for Payer: BCBS of TX Blue Essentials	$27.95
Rate for Payer: BCBS of TX PPO	$31.05
Rate for Payer: Cash Price	$52.79
Rate for Payer: Cigna Medicaid	$55.89
Rate for Payer: Molina CHIP/Medicaid	$55.89
Rate for Payer: Multiplan Auto	$50.46
Rate for Payer: Multiplan Commercial	$50.46
Rate for Payer: Multiplan Workers Comp	$50.46
Rate for Payer: Parkland Medicaid	$55.89
Rate for Payer: Scott and White EPO/PPO	$38.81
Rate for Payer: Superior Health Plan CHIP/Medicaid	$55.89
Rate for Payer: Superior Health Plan EPO	$10.56

Know your out-of-pocket cost for care.

All Charges